Social and Institutional Trust in the Bulgarian Health System

Abstract Background Trust builds the complex network of relationships in the healthcare system and supports the foundation of its effective functioning. The importance of trust has become more evident, especially during and after the COVID-19 pandemic. The aim of the study is to examine trust in the Bulgarian health system in two dimensions: social and institutional trust, which are distinct yet interconnected. Methods Social trust in healthcare providers was examined in 2023 through a cross-sectional, nationwide survey involving 1,292 respondents. Data were collected via a standardized online questionnaire. Trust was assessed using a five-point Likert scale, ranging from 1 (not trusted) to 5 (trusted very much). Institutional trust was analyzed using data from Eurofound surveys 2020-2024. Respondents rated their trust in the healthcare system on a scale from 1 (lack of trust) to 10 (full trust). Descriptive statistics and logistic regression analysis were performed to interpret the results. Results Findings regarding social trust reveal that 82.3% of respondents expressed high levels of trust in specialist physicians, 74.9% in general practitioners (GPs), and 50.7% in hospitals. The highest mean trust score was recorded for specialists (4.11), followed by GPs (3.92) and hospitals (3.31). Trust in the provider was a statistically significant predictor of GP visits and hospitalizations, with individuals who had higher levels of trust more likely to access these services than those with lower trust. Population-level trust in the healthcare system ranged between 4.1 and 4.4, with a positive trend observed from 2021 to 2024. Conclusions Future research should focus on identifying the key determinants of trust and on strategies for fostering and maintaining trust within broader health system policies. Sustained efforts to build and preserve trust are essential to ensure equitable access to healthcare and to enhance the overall effectiveness and resilience of the health system. Key messages • Measuring the different dimensions of trust is a crucial first step toward building and sustaining the complex network of relationships that underpin an effective healthcare system. • The study underscores the need for targeted strategies to strengthen trust in healthcare providers and institutions, fostering a more effective, resilient, and equitable health system.